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308: Clinical Pharamacology & Therapeutics > Cardiovascular drugs 2 > Flashcards

Cardiovascular drugs 2 Flashcards

1
Q

How do you diagnose HTN?

A
  • Record the lowest of 2 consecutive measurements in clinic
  • If above 140/90 offer ABPM
  • If unsuitable offer HBPM
  • Cut off for HTN on ABPM/HBPM is >135/85
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2
Q

Which activities/errors surrounding BP taking will affect the result?

A
  • Cuff too small
  • Cuff over clothing
  • Back/feet unsupported
  • Legs crossed
  • Patient not at rest for >5 minutes
  • Patient talking
  • Pain
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3
Q

Define the following terms:

a) (True) Normotensive
b) (True) Hypertensive
c) White coat hypertension
d) Masked hypertension

A

a) Normal ABPM/HBPM + clinic BP
b) HTN on ABPM/HBPM + clinic BP
c) Normotensive on ABPM/HBPM, HTN in clinic
d) Normotensive in clinic but HTN by HBPM/ABPM

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4
Q

> 90% of HTN are primary cases

Give 5 causes of secondary HTN

A

Renal disease- renovascular disease, renal parenchymal disease

Endocrine- Crohns, Cushings, Phaechromocytoma

Drugs- COCP, steroids, NSAIDs, cocaine, EPO

Vascular- coarctation of the aorta (presents in radio-femoral delay in young)

Other- OSA, pregnancy

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5
Q

Give 5 factors which contribute to the development of HTN

A

High BMI

> 14 units of alcohol/week

Salt intake

Lack of exercise

Stress

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6
Q

What are the risk factors for HTN?

A
  • M>F
  • Age
  • FMHx
  • Ethnicity (Africans, Asians)
  • Smoking
  • Cholesterol
  • Diabetes
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7
Q

Describe the pathophysiology of HTN

A
  • BP = CO x SVR

- CO= HR x SV

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8
Q

What are the symptoms of HTN?

A
  • Asymptomatic mainly

- Headache, blurred vision, dizziness, SOB, palpitations, epistaxis (nose bleed)

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9
Q

How do you examine a patient with HTN?

A
  • CV / Resp

- Abdo: for secondary causes e.g. Polycystic kidneys, renal masses

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10
Q

What investigations would you do in HTN?

A

Bloods: U&E, LFTs, Lipid profile, Glucose/HbA1c

Urinalysis

  • Haematuria: indicates possible renal cause
  • Proteinuria

ECG: for LVH, AF

-Fundoscopy to look for evidence of hypertensive retinopathy (best done by ophthamologists)

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11
Q

What is the prognosis if there is target organ damage?

A
  • HTN increases CV risk if target organ damage is present that risk increases more
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12
Q

First line pharmacological treatment for <55 patient not of Black origin

A

ACE inhibitor e.g. Ramipril

If not tolerated (due to cough) give ARB e.g. Losartan

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13
Q

First line pharmacological treatment for >55 yo patient, or black

A

CCB e.g. Amlodipine

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14
Q

If first line treatment is in effective what next?

And if this doesnt work?

A

Add a thiazide like diuretic

e.g. Indapamide

ACEi/ARB + CCB + Thiazide like diuretic

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15
Q

What is considered resistant HTN?

Management?

A

Requires >3 antihypertensives

  • Ask about adherance to medication
  • Check for postural hypertension

Consider adding

  • Low dose spironlactone is K<4.5
  • a-blocker/b-blocker if K>4.5
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16
Q

Give three side effects of amlodipine

A
  • Muscle cramps
  • Leg swelling
  • Constipation
  • Flushing
  • Palpitations
  • Headaches
17
Q

What tests should be done before starting on ACE-i?

Rules for titration?

Coprescription?

A
  • Check serum creatinine and K before starting
  • If K>normal, use is contraindicated
  • With every dose increment, repeat blood tests
  • If creatinine rises> 30%; GFR falls >25% or K>6 stop drug, repeat tests and exclude other causes
  • Exhibit caution when coprescribed with spirinolactone
18
Q

ACEi and ARBs are contraindicated in pregnancy and breast feeding. What alternatives can be used?

A
  • Labetalol
  • Methyldopa
  • Nifedipine/Amlodipine
19
Q

How do BP targets differ based on age when monitoring the effects of treatment

A

Age <80 years:
• Clinic BP <140/90 mmHg
• ABPM/HBPM <135/85 mmHg

Age ≥80 years:
• Clinic BP <150/90 mmHg
• ABPM/HBPM <145/85 mmHg

20
Q

How do proteinuria targets differ with ACR

A

Proteinuria low if
Albumin:creatinine (ACR) <70
or protein:creatinine (PCR)<100
Target BP should be <140/90

Proteinuria high is
ACR >70 or PCR >100
Tighter BP target off <130/80

21
Q

Discuss the use of ACEi and ARBs in patients with proteinuria

A

They should be used in patients with urinary ACR>30 or PCR>50

Also in diabetic patients with microalbuminuria

22
Q

Why does HTN treatment fail?

A
  1. Pseudo-resistant HTN: due to non adherence, white coat effect
  2. Secondary hypertension: underlying cause persists
  3. Resistant HTN
23
Q

Which patients are particularly at risk of developing hyperkalaemia?

A

Those with impaired renal function

24
Q

What considerations need to be made when treating an older patient?

A
  • Treat in accordance to higher targets of 150/90
  • Check for postural hypertension
  • Use clinical judgement
25
Q

Define the two types of hypertensive crises

A

1) Hypertensive emergency
- severe HTN (BP>180/110) with acute damage to the target organs
- need to lower BP in minutes-hours

2) Hypertensive urgency
- severe hypertension without acute damage to the target organs
- lower BP in 1-2 days

26
Q

What are the symptoms of a hypertensive crisis?

A
  • Asymptomatic
  • Headache
  • Epistaxis
  • Presyncope
  • Palpitations
  • Chest pain
  • Dyspnoea
  • Neurological deficit
27
Q

When and how should statins be used for primary prevention of CVD?

A
  • CVD risk shouldl be estimated
  • Offer lifestyle modification first
  • Offer atorvastatin if risk >10% or if above 85yo
  • Offer in diabetes, CKD, familial hypercholesterolemia
28
Q

What end organ damage can occur as a result of a hypertensive crisis?

A
  • Eyes: papilloedema
  • Brain: encephalopathy, stroke
  • Heart: pulmonary oedema, MI
  • Kidneys: AKI
  • Aortic dissection
29
Q

When and how should statins be used for secondary prevention of CVD?

A
  • Do not delay initiation to manage modifiable risk factors

- Start statins in those with CVD

30
Q

When should you not use a risk assessment tool to assess CVD risk?

A
  • In those with eGFR<60ml/min/1.73m

- And/or those with albuminuria

31
Q

Which blood tests should be done before the initiation of statin therapy?

A
  • Lipid measurement
  • LFTs (3x upper limit of normal)
  • Renal function
  • HbA1C
  • TSH
  • CK (5x upper limit of normal)
32
Q

Is any monitoring necessary with statins?

A

After three months

  • measure lipid: should be a 40% reduction in non-HDL cholesterol
  • measure LFTs
  • CK if symptoms
  • Annual medication review
33
Q

If statins are not tolerated what is the alternative?

A

Stop, reduce dose, or switch statin

Seek specialist input

Avoid fibrates

Ezetimibe
- may be coadministered with statin if appropriate

34
Q

A patient presents with hypertriglycerridaemia.

What should you exclude first?

For each TG range give the

A
  • Exclude excess alcohol and poor glycaemic control

TG>20mmol/l- refer to specialist
TG: 10-20mmol/l- do a repeat fasting sample within 2 weeks. If >10mmol/l refer
TG: 4.5-9.9mmol/l- check CVD risk and correlate with cholesterol

Specialsits will give omega 3, fenofibrates

35
Q

A 62-year-old man has recently been started on atorvastatin 80mg following an MI and complains of muscle aches and weakness.

Investigation Results:Serum creatine kinase 2306 U/L (24–195).

What is the most appropriate therapeutic decision regarding the atorvastatin prescription?

A

Lower the dose

Serum CK raised due to myopathy
Risk of rhabdomyolysis (more severe myopathy)

Those at increased risk of myopathy are (diabetics, elderly, hypothyroidism, liver or kidney disease)

36
Q

Which risk calculators are used for CV risk?

A

QRISK2/3 - provide 10 year CV risk

JBS3- provides lifetime risk

37
Q

How do statins reduce CVD risk?

A

Increase uptake on LDL from circulation

Work independent of cholesterol lowering

38
Q

What lifestyle management is given for HTN?

A
  • Weight reduction (BMI between 20-25)
  • DASH eating plan
  • Sodium restriction
  • Physical activity
  • Alcohol moderation

308: Clinical Pharamacology & Therapeutics (10 decks)

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